Context: Low back pain (LBP) is a common public health problem, and has a multifactorial etiology that includes not only physical risk factors, but also psychosocial factors. There were several studies that investigated physical and psychosocial factors and their relationship with LBP. However, up to the researchers' knowledge, no studies have been conducted in Saudi Arabia.Aims: To investigate physical and psychological factors in Saudi population with LBP.Settings and Design: A case-control study using self-report measures.Materials and Methods: Arabic versions of the following self-report measures were applied: A 10-cm Visual Analogue Scale (VAS) to measure pain intensity; the International Physical Activity Questionnaire (IPAQ) to record average physical activity levels over the last 7 days; and Depression, Anxiety and Stress Scale (DASS) to measure the negative emotional states of depression, anxiety and stress. The above self-report measures were handed to the participants and were collected immediately. Thirty-one patients with LBP and thirty-one control participants matched in body mass index and age participated.Statistical analysis used: Independent t-tests and Pearson Correlation Analysis were used to calculate differences in VAS, IPAQ and DASS between the two groups.Results: Patients with LBP had moderate stress compared to control participants (19.8 and 4.4 respectively, P = 0.0013). Both groups did not present with anxiety or depression. No significant difference was found in any level of activity between the groups.Conclusions: Stress was present in this group of Saudi patients with LBP. Targeting psychological factors associated with LBP, not only physical factors may help improve the management of patients with LBP.

Low back pain (LBP) is one of the most frequent medical causes of disability and absence from work. [1] Al-Arfaj et al., [2] reported that the prevalence of LBP in Al-Qaseem area of Saudi Arabia was 18.8%. Some musculoskeletal disorders such as LBP have a multifactorial etiology that includes not only physical risk factors, but also psychosocial factors. [3] Psychosocial factors can also cause and aggravate significance LBP from a much earlier stage than previously believed. [4],[5]

There are several studies that investigated physical and psychosocial factors and their relationship with LBP. For example in Sweden, a study found that interactions between few or unsatisfactory social contacts outside work and dissatisfaction with leisure time increased the risk of LBP among both genders. [6] In another study on Danish female nursing personnel, only stress was associated with LBP while neither physical exertion or any of the psychosocial factors, such as time pressure, emotional demands of clients, control and social support, were related to LBP. [7] More recently, Kennedy et al., of the United States found that the stressful psychosocial variables of feeling very sad, exhausted and overwhelmed were associated with the prevalence of LBP. [8] In an Arab population, Bener et al., found that anxiety and depression were significantly associated with LBP. [9]

The previous studies show some contradictions in the results. This may partially be attributed to several reasons such as different self-report measures used, different population characteristics and/or different cultures. The latter may indicate that religious, spiritual and social cultural factors have an effect on the results. Majority of these studies have been conducted mainly in western countries in North America, Europe and Australia. [7] As far as the researchers' knowledge is concerned, no studies have been conducted in Saudi Arabia to investigate the relationship between physical and psychosocial factors and pain in patients with LBP. The aim of this study was to investigate the physical and psychological aspects of LBP in a group of Saudi patients with LBP.

Materials and Methods

Study design

A case-control study using self-report measures to examine physical and psychological factors associated with LBP in adult participants with and without LBP.

Sample calculation

The G*Power software (version 3.1.7, Universität Kiel, Germany) was used to calculate the sample size from pilot data of ten patients and ten normal participants using a one-tailed test of the difference between proportions with 80% power and a 5% signiﬁcance level. A sample size of 61 participants (30 in each of the patient and control groups) was sufficient to detect the difference in the outcome measures between both groups.

Sample characteristics

During a 3-month period (February to April 2013), data were collected consecutively from patients with LBP who were seeking treatment in hospitals of the Eastern Province of Saudi Arabia (convenience sampling). The inclusion criteria for patients were: An adult age, LBP (symptoms from the region of the back between L1 and the gluteal folds); lifetime LBP severity >3/10 for their worst ever LBP on a visual analogue pain scale; duration of LBP in previous 12 months >1 week [to differentiate subjects with a single, very short episode of LBP] [10] and LBP requiring treatment or medication or a reduction in activity in the past 12 months. [11] The exclusion criteria for patients were: Conditions affecting the spine or lower limbs including inflammatory disorders, neurological diseases or metastatic disease. The inclusion criteria for control participants were matched age and body mass index (BMI); no lifetime LBP severity >3/10 for their worst ever LBP on a visual analogue pain scale and LBP requiring treatment or medication or a reduction in activity in the past 12 months.

Self-report measures

The following self-report measures were the outcome measures used in the study:

Visual Analogue Scale (VAS). The VAS has been considered to be one of the best measures of pain intensity with high reliability and validity. [12] It consisted of a vertical or horizontal line of 10 cm in length with extreme anchors of ''no pain'' to ''extreme possible pain.''

International Physical Activity Questionnaire (IPAQ). Physical activity level over the last 7 days was assessed using the official Arabic short-version of IPAQ (www.ipaq.ki.se). Craig et al., [13] found acceptable reliability and validity of IPAQ over 12 countries although an Arab country was not included in their study. However, they suggested that IPAQ could be used with confidence in developed countries or in developing countries with some caution in rural or low literacy population. IPAQ is an instrument designed to ask about three specific types of activity [low-intensity (walking), moderate-intensity and vigorous-intensity] across a range of domains including domestic and gardening, work-related, transport-related and leisure time physical activities. Data were summed across the domains to give weekly averages (in hours) of time spent doing the activity.

Depression Anxiety and Stress Scale (DASS).The Arabic version of DASS, which demonstrated high internal consistency and reliability [14] was used in this study. The DASS is a 42-item questionnaire which includes three self-report scales designed to measure the negative emotional states of depression, anxiety and stress. Each of the three scales contains 14 items, divided into subscales of 2-5 items with similar content. The Depression scale assesses dysphoria, hopelessness, devaluation of life, self-deprecation, lack of interest/involvement, anhedonia and inertia. The Anxiety scale assesses autonomic arousal, skeletal muscle effects, situational anxiety and subjective experience of anxious affect. The Stress scale is sensitive to chronic non-specific arousal and assesses difficulty relaxing, nervous arousal, being easily upset/agitated, irritable/over-reactive and impatient. Respondents will be asked to use 4-point severity/frequency scales to rate the extent to which they have experienced each state over the past week.

Procedure

This study has been approved by the Institutional Ethical Committee. Each participant who agreed to be part of the study, signed a consent form. In the first section of data collection, information on demographic data and pain was collected. During the second section, all the above self-report measures were handed to the participants and then collected immediately after the participants filled them.

Data analysis

Statistical analyses were performed using the IBM SPSS, version 19 (IBM Corporation, Somers, NY, USA) and PAST (Paleontologica Statistics, version 2.17c). [15] Descriptive statistics of means, standard deviations, medians and interquartile ranges were computed to present the basic features of the data. Data processing and analysis of the IPAQ were based on the scoring protocol of the guidelines published in November, 2005 (http://www.ipaq.ki.se/scoring.htm, accessed August 24, 2013). The following equations were applied: Low (walking) MET-minutes/week = 3.3 × walking minutes × walking days; moderate MET-minutes/week = 4.0 × moderate-intensity activity minutes × moderate days; vigorous MET-minutes/week = 8.0 × vigorous-intensity activity minutes × vigorous-intensity days; total physical activity MET-minutes/week = sum of low + moderate + vigorous MET minutes/week scores. Scores of Depression, Anxiety and Stress subscales were calculated by summing the scores for the relevant items to these sub-scales. Then the score over each of the subscales were evaluated as per the severity-rating index: Normal, mild, moderate, severe and extremely severe. [16][Table 1] shows scoring and grading of DASS questionnaire. Differences between the two groups in the dependent variables (VAS, IPAQ and DASS) were tested using independent t-tests. The correlations between these variables were tested using Pearson's Correlation. The level of statistical significance was set at P < 0.05.

The response rate of all self-report measures was very good (77.5%). The remaining percentage of questionnaires (22.5%) was not returned by the participants. The results of these measures are shown below.

VAS: As expected, there was a significant difference between the patients and control participants in pain at three stages [Figure 1].

DASS: Patients had significantly higher scores than control participants in all subscales: Depression, anxiety and stress [Table 4]. However, the severity-rating index for depression and anxiety were within normal limits for both patients and control groups. On the other hand, patients had moderate stress (19.8) compared to control participants (4.4) who did not demonstrate stress.

Relationship between VAS, IPAQ and DASS: The Pearson Correlation Analysis showed weak, non-significant correlations between the variables in the patients.

Discussion

The results of the current study indicate the importance of psychological stress in patients with LBP. There was no evidence of depression or anxiety in these patients. In addition, this study did not reveal a significant difference in the level of physical activity between patients and control participants.

The results of this study are comparable to those studies in western society. The results support the study of Gonge et al., [7] who found that only stress, but not physical exertion or any of the psychosocial factors, such as time pressure was associated with LBP. In the United States, Kennedy et al., [8] investigated psychosocial factors of stress and their effects on the prevalence of LBP among college students. They found that the stressful psychosocial variables of feeling very sad, exhausted, and overwhelmed were associated with the prevalence of LBP. A more recent study done in Australia found a significant difference between patients and controls in stress, but not anxiety or depression. [5] On the other hand, a recent Qatari study [9] and an earlier Iranian study [17] found depression and anxiety in patients with LBP, which contradicts with our results that showed depression and anxiety were not present in both patients and control groups. An Australian study found that patients with acute LBP have feelings of depression. [18] This difference in the results between studies maybe due to several reasons, such as culture and environment of the study and the methodology used. [9]

This study found no significant difference in the level of activity between patients and control participants. While some studies reported a relationship between physical activity and LBP. [19] Other studies, found lack of this association in another population. [20] Mitchell et al., [5] suggested that inconsistency in the studies about the association between physical performance and LBP cannot be explained entirely by method differences. An explanation maybe that physical performance measures are only relevant when they relate to the mechanical exposures of people being investigated. [5]

Several mechanisms for the relationship between stress and LBP have been proposed. For example, a study showed a number of stress biomarkers in patients with musculoskeletal pain, associated with regenerative/anabolic activity and decreased levels of neuropeptide Y (NPY), albumin, growth hormone (GH), high density lipoproteins (HDL) and dehydroepiandosterone sulphate (DHEAS-S), [21] which maybe associated with altered regulation of the hypothalamus-pituitary-adrenal axis. [22] Another mechanism maybe due to the influences of emotions such as stress, on descending inhibitory pain modulation systems and central descending tonic pain inhibition. [23],[24],[25] Other psychological mechanisms maybe involved to several aspects of psychosocial functioning in LBP patients. For example, Janowski et al., [26] found that cognitive disease-related appraisals, coping strategies, social support and personality were associated with psychosocial functioning in patients with chronic LBP.

This present study did not find correlation between LBP and the levels of physical activity, depression, anxiety, or even stress. Contrary to our results, Bener et al., [9] found that psychological distress was associated with increased risk of LBP using Chi-square Analysis and/or the Fisher's exact test. The current study did not investigate the causality between LBP and psychological factors. Therefore, this study cannot differentiate whether increased stress is caused by having LBP or is a characteristic of the person. However, it has been reported that pain can result in psychological distress. [27] Mitchell et al., [5] on the other hand, suggested that high stress was less likely to be related to current pain in their patients with chronic pain. This suggestion may apply to the current study as the patients had chronic pain similar to the patients in Mitchell et al., study. An earlier study found that majority (58%) of the patients with LBP stated that their psychological problems started before their pain. [17] The authors suggested that anxiety may have played a role in the onset, maintenance or exacerbation of the pain. [17]

The average age of the population in the current study was approximately 25 years. Previous studies found negative psychological aspects associated with LBP in a population with similar age. Kennedy et al., [8] investigated the underlying reason regarding incidence of pain related to the lower back in college students studying in a major university in Colorado. The authors determined the psychosocial effects like stress on the pervasiveness of LBP in this population. Among the five psychosocial stress and strain aspects examined (feeling overwhelmed, feeling of hopelessness, feeling very sad, feeling depressed, as well as feeling exhausted), three of them were considerably correlated to LBP: Feeling very sad, feeling fatigued and feeling overwhelmed. [8]

Generalization of the finding of this study has to be considered with caution because the sampling method was not random (convenience sampling). However, the appropriate sample size used based on the sampling calculation and involvement of the matched control group strengthens the external validity of this study. Another point to consider is that the average age of the population of this study was 25 years. These findings in this younger population may not be generalizable in older population who demonstrated other psychological aspects. [9] Moreover, subgrouping of LBP was not considered in this study which may have revealed other physical and/or psychosocial aspects, associated with different subgroups of LBP patients. [28] Future researches may investigate different population taken into consideration the previous issues in order to have stronger argument for extrapolation of the results.

In conclusion, the findings of this study suggest that this group of Saudi patients with chronic LBP had an increased occurrence of coexistent psychological issues. Patients experienced more stress than control participants. The findings acknowledge the importance of psychological assessment and treatment, in addition to biomedical aspects when managing patients with LBP.

Acknowledgment

The author would like to thank Mr. Ahmed Alomar, Mr. Ahmad Al-Ghamdi, Mr. Mohammed Al-Azmi, Mr. Naif Al-Dossary and Mr. Fahad Al Anzi for their valuable help in data collection and management. The author is also grateful to Prof. Sulaiman Bah for data analysis.